Sen. Ujifusa, Rep. McGaw introduce bill to protect patients from insurers’ step therapy protocols

State House — Sen. Linda Ujifusa and Rep. Michelle E. McGaw are sponsoring legislation to rein in so-called step therapy protocols used by health insurance companies that can delay or prevent patients from getting tests, procedures and drugs ordered by their physicians.

Step therapy, also known as “fail first” therapy, is a health insurance practice which requires patients to try less expensive treatments before more costly ones are covered. Although step therapy is meant to give patients proper health care while managing costs, it has also been used to delay, disrupt and even prevent patients’ access to necessary health care and interfere with physicians’ ability to make decisions based on what is best for the patient.

The legislation (2024-S 2611, 2024-H 7822) introduced by Senator Ujifusa (D-Dist. 11, Portsmouth, Bristol) and Representative McGaw (D-Dist. 71, Portsmouth, Tiverton, Little Compton) provides that insurers cannot use step therapy if the step required is:
• contraindicated by the patient’s other drugs or therapies,
• expected to cause an adverse reaction,
• has been tried and found ineffective or is expected to be ineffective,
• will delay or prevent medically necessary care or
• will disrupt the patient’s current effective drug regimen.

“The bill sets parameters around step therapy to be sure that our health care providers have greater agency in determining what is most appropriate for patients,” said Representative McGaw, who works as a licensed pharmacist.

During a hearing on the bill, Representative McGaw shared the story of a family member who needed surgery, but was required to go through a litany of step therapy options before surgery would be approved, causing months of pain, suffering, added costs and missed work, only to ultimately require surgery after all.

“Step therapy cannot be allowed to be one more ‘utilization management’ tool used by insurers and pharmacy benefit managers to prioritize their financial interests over patient welfare,” said Senator Ujifusa.

Thirty-six states have already enacted laws that explicitly limit step therapy, and federal legislation was introduced last year, although it has not advanced in Congress. Because of its lack of governance on this issue, Rhode Island has been given an "F" grade by the National Organization for Rare Disorders on its state report card on step therapy policies.

Multiple patient advocacy groups, including the American Cancer Society Cancer Action Network, the National Organization for Rare Disorders, the ALS Association, the Chronic Disease Coalition, the Rhode Island Medical Society and Newport Mental Health, as well as many local primary care providers support the Rhode Island bill.

The House Health and Human Services (HHS) Committee held a hearing on the House bill March 19, and the Senate HHS Committee is expected to hear the Senate bill in the coming weeks. Senator Ujifusa and Representative McGaw urge patients and their advocates to submit testimony by email as soon as possible with the subject line “In support of S2611 and H7822,” describing their reason for supporting the bills, including any personal challenges with step therapy. Testimony can be sent to the Senate HHS Committee at www.SLegislation@rilegislature.gov  and to the House HHS Committee at www.HouseHealthandHumanServices@rilegislature.gov.